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Joseph Benissois, right, queries Presandieu Charles on his mental state during a home visit in June. Benissois has worked as a community health worker in the Haitian town of Cange for more than 30 years.

This is the first part of a three-part story on the role of community health workers in rural health care from the Montana Gap project. Part one: What’s working abroad? In rural Haiti, locals trained as community health workers help mentally ill neighbors where full-fledged physicians are few and far between.

As a child, Presandieu Charles suffered severe headaches and stomach pains. One day he beat his mother on the foot and thigh with a stick, and later cried when he saw what he had done.

In October 2017, Charles began to hammer at the timber walls of his family’s dirt-floored home with his fists. He would not stop. Neighbors bound his ankles and wrists with leather straps and metal chains. They called his affliction “the madness.” He still has the scars: dark star-shaped marks on the skin on his right wrist.

The house perches on the edge of a lush, forested ridge several miles outside Cange, a remote Haitian village near the Dominican border. Inside it is cool, and slivers of light stream through the white lace curtain hanging in the front door frame. Charles’ shoulders droop as he sits on a bed dressed with Pokémon sheets. The 24-year-old wears an Adidas t-shirt and plastic Nike sandals. Beside him is Joseph Benissois, a local community health worker with the Boston-based global health nonprofit Partners in Health (known in Haitian Creole as Zanmi Lasante). The two exchange no small talk, and Benissois begins to ask Charles questions from a clipboard in his lap. Charles doesn’t often smile as Benissois asks them. When he does, though, it’s a sweet, knowing flash of pride at the progress his answers reveal.

Does he cry? Not as often as he used to.

Does he have difficulty sleeping? No, but he feels weak when he wakes, and he has trouble going to the garden or fetching water. That might be the drugs he is taking.

Does he feel bad or uncomfortable with himself? In the past he felt bad. Now he tells jokes to the friends he sees on the street, smiles and laughs with them.

In the past 15 days, has he wanted to die? “He used to say to himself that it’s better if he died, but not now,” an interpreter relays.

Partners in Health, which was founded just down the road in Cange by renowned physician and humanitarian Paul Farmer, has been recruiting and training individuals like Benissois since the late 1980s and placing them on the frontlines of the organization’s efforts to combat cholera, HIV and other major health threats. But the 2010 earthquake that devastated this rugged Caribbean nation — killing an estimated 220,000 people, injuring more than 300,000 more and leaving some 1.5 million homeless — brought to the forefront another widespread Haitian health risk: This country of more than 10 million people had only 10 psychiatrists. The loss of homes, jobs and loved ones in the quake triggered a rash of depression that Haiti’s few specialists, already struggling to treat a host of other mental-health issues, were ill-equipped to handle. In the central plateau, Partners in Health tasked its community health workers to help fill the gap in mental-health coverage.

The questions Benissois asks Charles come from a depression symptom inventory developed by the nonprofit. They’re identical to those asked by its 58 other mental-health-focused CHWs. Since April 1987, Benissois has worked with the organization as a CHW (or accompagnateur in Creole), a non-specialist position designed to provide patient check-ups and administer basic health care in small, remote communities. The model traces its roots back to the mid-1950s and China’s so-called barefoot doctors: farmers and other villagers who received short-term medical training to meet immediate needs in isolated towns. Gradually embraced and refined by the global health community over subsequent decades, the model is now a vital component of health-care strategies in scores of developing nations, and is being increasingly implemented in the United States. In fact, after five years of coordinated development by various stakeholders, Montana recently rolled out a CHW training curriculum of its own to support statewide implementation of a model that the Montana Office of Rural Health/Area Health Education Council says is proven to increase health-care access, reduce costs and improve responsiveness to patient needs. That the timing of that roll-out coincides with state budget cuts and widespread layoffs among community-based health-care service providers is entirely coincidental.

Benissois is a familiar face in the hills around Cange, having served as the local pastor and a community advocate for more than 30 years. He visits as many as 20 patients a month throughout the Cange and nearby LaHoye regions. Occasionally, he’ll take a moto — a motorcycle taxi, one of the more popular modes of transportation in Haiti — to visit people like Charles. Today he’s on foot, shuffling with a lopsided gait along the shoulder of the highway, smiling casually to those he passes and greeting them with a familiar “bonjour.”

Benissois visits Charles once a month. While Charles keeps regular appointments with Partners in Health physician Reginald Fils Aime in Cange, and is currently taking antipsychotic medications, the at-home check-ups with a trusted neighbor free him from having to make extra trips — a mile walk each way — to the clinic. When asked what the veteran CHW has done to help him, Charles wraps an arm around Benissois and beams.

“I love him so much,” Charles says. “He is my father and Jesus Christ.”

That Montana, an isolated, largely rural state nearly 3,000 miles from Haiti and, geographically, nearly 14 times the size, has recently embraced the CHW model in the face of its own health-care challenges makes the organization’s decades of work a compelling case study. Though culturally distinct, the two areas share many commonalities: remote populations, impoverished communities and, particularly in the wake of last year’s cuts to Montana’s mental-health budget, a pressing need for local solutions. And if the benefit that Benissois delivers to Charles is any indication, CHWs could become a valuable asset for Montanans as well.